The Journal - Focus on Cardiac Advances - Spring 2019

Spring 2019
THE JOURNAL
FOCUS
ON CARDIAC ADVANCES
INSIDE:
Evolution of Cardiovascular Services TAVR
Cardiac Surgery
Advanced Diagnostics
Cardiac Medical Management
A publication of Cape Cod Health News


Your doctors. Your health news. All in one place.
THE JOURNAL
ADMINISTRATION
Michael K. Lauf
President and CEO
MARKETING
Patrick Kane
Senior Vice President Marketing, Communications and Business Development
EDITOR
Robin Lord
Communications Director
ART OPERATION
Deb Barnes
Art Director & Graphic Designer
DESIGN
95 North
PHOTOGRAPHY
Julia Cumes
CONTRIBUTORS
Jan Aubrey, RN
Director Physician Outreach/Referral
Julie Badot
Manager Marketing Communications
Patricia Pronovost
Marketing Program Manager
Mary Pumphery
Administrative Assistant
Jeanne Sarnosky
Manager Marketing Communications
Michael Seeley
Web & Digital Specialist
Cape Cod Healthcare
88 Lewis Bay Road, Hyannis, MA 02601 p: 508-862-5177
e: [email protected]
On the web at www.capecodhealth.org
Members of the Cape Cod Healthcare system are Cape Cod Hospital, Falmouth Hospital, Cape Cod Healthcare Foundation, The Visiting Nurse Association of Cape Cod, CCHC Lab Services, Bourne Health Center, Fontaine Outpatient Center, Rogers Outpatient Center, Stoneman Outpatient Center, Wilkens Outpatient Medical Complex, Oppenheim Medical Building, Clark Cancer Center, Davenport-Mugar Cancer Center, Heritage at Falmouth, JML Care Center, Centers for Behavioral Health, Cape Cod Health Network, Medical Affiliates of Cape Cod and Emerald Physicians
ON THE COVER
(L to R): Physicians Tendoh Timoh, MD, FACC; Richard Zelman, MD, FACC; Elissa Thompson, MD; and Paul Pirundini, MD at the Cape Cod Healthcare Heart & Vascular Institute
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HEALTHCARE IN THE FIRST PERSON
Michael K. Lauf
President and CEO, Cape Cod Healthcare
The Cardiac Service line at Cape Cod Hospital and Falmouth Hospital has evolved over the past 30 years into a nationally recognized program, thanks to a dedicated group of physicians and administrators who recognized the value of this program to the people of Cape Cod. The level
of expertise, technological capability and care
in our cardiovascular services is a large part of why Cape Cod Hospital has become a regional tertiary medical center performing procedures unheard of in other communities like ours.
When we launched the Cape Cod Healthcare Heart & Vascular Institute in 2014, we were capitalizing on this advanced level of care available in our cardiovascular service line by bringing together the skill and expertise of
our board-certified cardiovascular specialists backed by the full resources of the Cape’s leading healthcare system. The partnership has strengthened over the last four years, and we are now bringing a suite of new lifesaving and life-altering procedures to patients on-Cape and over the bridges.
Our cardiac physicians trained in some of
the best places in the nation, like Brigham
and Women’s Hospital, St. Elizabeth’s Medical Center, Harvard Medical School, Cleveland Clinic, New England Deaconess Hospital, Walter Reed Army Medical Center, Tufts University School of Medicine and Dartmouth-Hitchcock Medical Center. When they came to the Cape, they brought their vast set of skills and their considerable experience to this peninsula
and this healthcare system because they
saw an opportunity to build and maintain
a top-notch program.
They are supported by an incredible group of nurses, cardiac technologists, anesthesiologists, perfusionists and others, who have also trained in some of the best institutions and have honed and perfected their skills over time.
I am continually amazed by the growth and sophistication of our cardiac team and their attunement to the latest and best procedures, technology and innovation so that patients on Cape Cod have the privilege of staying close
to home for the absolute best care. One of my responsibilities as CEO of this health system is
to work with our board of directors to provide the resources that our physicians need to provide this level of care. It has been my great privilege to preside over the last seven years of this evolution, and watch as we continue to launch exciting new aspects of the program.
In this issue of The Journal, you will learn about some of these incredible new procedures and technology, like the transcatheter aortic valve replacement (TAVR), an interventional cardiology procedure for patients who are too sick or frail to undergo open heart surgery. Dr. Richard Zelman, along with cardiac surgeons Dr. Paul Pirundini and Dr. Dan Loberman,
continued on page 48


EXPERT PHYSICIANS. QUALITY HOSPITALS. SUPERIOR CARE.
The Cape Cod Healthcare Heart & Vascular
Institute was created in 2014 and established
an unprecedented partnership between Cape Cod Healthcare (CCHC) and cardiovascular physicians on Cape Cod. It brought together the skill and expertise of board-certified cardiovascular specialists and the full resources of CCHC in order to deliver top-quality cardiac and vascular care to the region.
The CCHC Heart & Vascular Institute physicians are highly trained and experienced in the diagnosis and comprehensive, evidence-based treatment
of cardiovascular diseases and conditions. The Institute features:
• Outcomes that compare with the best medical institutions in the country
• Top cardiovascular physicians coordinating care on one team
• The latest screening and education resources
• A continuum of care from diagnosis, to treatment, to follow-up
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Dr. Zelman and several other physicians from other community hospitals begin lobbying the state Legislature to allow medical centers to perform emergency angioplasty procedures. He enlists the hospital in a randomized clinical trial run by researchers at Johns Hopkins University, whereby heart attack patients are randomly chosen to receive either angioplasty or clot-busting drugs.
A 61-year-old heart attack patient, Barbara Galvin, is brought into the CCH ER in critical condition. As part of the clinical trial, she is randomly chosen to receive the clot-busting drugs. Dr. Zelman realizes the drug is not working and she will not survive. He goes against the state regulations and performs balloon angioplasty on the now comatose Galvin. She survives and lives another 17 years.
1998
LATE 1990s
Interventional radiologist Philip Dombrowski, MD, who had arrived at CCH a few years before, begins working closely with Dr. Zelman and they begin doing research together.
Cardiologist Richard Zelman, MD, FACC, joins the practice of cardiologist Lawrence McAuliffe, MD, FACC, at a time when hospitals are adopting cardiac catheterization, giving doctors a new way to diagnose and treat diseases. Dr. McAuliffe becomes the first community-based cardiologist with Cath Lab privileges at a Boston facility (Beth Israel-Deaconess).
1970s and 1980s
John Bete, Sr, MD; Grover Farrish, MD; John Arthur, MD; and John Tenbrook, MD; are among the first cardiologists to practice at CCH. Cardiac Rehab opens at Falmouth Hospital in 1987.
1990
A study published in the New England Journal of Medicine demonstrates that heart attack victims who are treated with emergency angioplasty are more
likely to survive and less likely to 1995 experience serious side effects. Cape
patients are still sent off-Cape for angioplasty procedures.
1993
1994
Dr. McAuliffe and other colleagues open a mobile catheterization lab at Cape Cod Hospital (CCH), and at Falmouth Hospital (FH) once a week. Massachusetts law only permits hospitals to perform elective and emergency angioplasty if the institution has a cardiac surgeon on site as a back-up.


FPO
Dr. McAuliffe testifies to the state Legislature on behalf of the bid to open a cardiac surgery program at Cape Cod Hospital. The hospital is awarded one of three new open heart surgery programs in the state – the first non-tertiary care hospital in 25 years.
Cape Cod Healthcare and cardiovascular specialists join forces to launch the CCHC Heart & Vascular Institute. Minimally invasive cardiac procedures emerge. Cardiac surgeon Dan Loberman, MD, begins performing mini mitral valve repair procedures. Cape Cod Hospital launches a Cardiac Hospitalist program.
2000
Cape Cod Hospital begins 2016 providing elective angioplasty
procedures, due to the presence of
a cardiac surgery backup program.
Cardiac electrophysiologist Peter Friedman, MD, PhD, FACC, FHRS, and Dr. Zelman provide a new procedure for patients with persistent atrial fibrillation, the left atrial appendage closure using the WatchmanTM device. CCH launches cardiac imaging program with cardiac imaging specialist
Tendoh Timoh, MD, FACC.
Dr. Friedman provides the MicraTM Transcathe- ter Pacing System, a procedure for patients in need of a pacemaker in the lower chamber of the heart.
2014
1999
2002
2001
2015
Cape Cod Healthcare enters into a
cardiac surgery partnership with
Brigham and Women’s Hospital, 2017 bringing the first cardiac surgeon
and team to Cape Cod.
NBC news show Dateline airs a segment about Galvin’s case. In response to the dramatic story and the hospital’s growing track record with the Hopkins trial, the state Department of Public Health grants the hospital special permission to perform emergency angioplasty and stenting, despite not having a cardiac surgeon on site.
Dr. Zelman and the cardiac surgeons begin performing transcatheter aortic valve replacement (TAVR), for patients too frail for open heart procedures. The team also begins providing another procedure, transcatheter mitral valve repair (TMVR).
Integral to the success of the CCHC Heart & Vascular Institute are the support specialists
who work closely with the physicians to produce exceptional outcomes. While physicians can make complex cardiovascular medical procedures, such as the transcatheter aortic valve replacement (TAVR), mini mitral valve surgery and the left atrial appendage closure (LAAC) appear routine, each will tell you they could not do it without their medical teams. The group includes physician assistants, nurse practitioners, nurses, cardiac technicians and technologists, anesthesiologists, perfusionists and office staff.
The CCHC Heart & Vascular Institute catheterization lab, operating room, and office teams each work together seamlessly, with a well-orchestrated, consistent methodology, which ensures that detailed processes are repeated, followed and executed.
This dedicated approach ensures that every patient will have as good an outcome as possible.
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CONTENT
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PROGRAM EVOLUTION
ELECTROPHYSIOLOGY
1
A Generation of Transformation
Advanced cardiovascular procedures close to home on Cape Cod.
8
Open Heart Surgery – Without the ‘Open’
TAVR offers some heart valve patients a less invasive option.
12
Still the Gold Standard
Open heart surgery remains the go-to procedure for some cardiac conditions.
17
This Patient is Doing Better Now than 10 Years Ago
Mini mitral valve surgery restores health and vigor.
20
A ‘Very Attractive’
Alternative to Taking
Blood Thinners
New device can effectively treat AFib in some patients.
24
A Pacemaker the Size of a Vitamin Capsule
Wireless device inserts directly into the heart.
10
A Minimally Invasive Way to Avoid Congestive Heart Failure
TMVR using MitraClip® device.
SURGERY


RECOVERY
VASCULAR SURGERY
DIAGNOSTICS
31
A Cardiologist by
the Bedside
Program offers inpatient care for cardiac concerns.
27 34 42
Less-Invasive
Aneurysm Repair
Relieving AAA symptoms, preventing rupture and prolonging life.
Recovering and Thriving
Images That Help Guide
Advanced-Care Cardiology
Specially trained cardiologist interprets detailed images.
Features
47 Women and Health
After Cardiac Rehab
Program offers cardiac patients a place to rebuild their strength.
39
Heart Failure Clinic
Helping patients learn how to manage symptoms and avoid readmission.
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Richard B. Zelman, MD, FACC, chief of inpatient cardiology, Cape Cod Healthcare


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A GENERATION OF TRANSFORMATION
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Not long ago, Cape Codders in need of advanced cardiovascular procedures had to travel to Boston. But Cape Cod Hospital now has an elite interventional cardiovascular service, which saves trips over the bridge – and lives.
By Timothy Gower
The patient was a 70-year-old man with a failing heart valve. Eight years earlier, doctors had performed cardiac surgery to replace his aortic valve – the valve that must open in order for the heart to pump blood to the rest of the body, and then close tightly to ensure that the life-giving fluid doesn’t leak back in. But
the replacement valve no longer opened and closed efficiently, leaving the man constantly short of breath and at risk of sudden rupture and certain death.
Replacing the patient’s failing artificial heart valve in another round of open heart surgery was an option, but not a good one. Making a second large incision
in his chest and separating the rib cage again would have been difficult and risky. So instead, interventional cardiologist Richard Zelman, MD, FACC, along
with a multidisciplinary team of cardiac surgeons, interventional radiologists, cardiac anesthesiologists, nurses, perfusionists, and technologists, assembled in the Cardiovascular Catheterization Lab (Cath Lab) at Cape Cod Hospital one afternoon last autumn to treat the patient with a minimally invasive procedure known as transcatheter aortic valve replacement (TAVR).
Under mild sedation and local anesthesia, a small needle was inserted into the patient’s femoral artery and used to introduce a tube called a catheter which was then guided upward through the aorta and ultimately toward the patient’s heart. Attached to the catheter
was a new aortic valve fashioned from cow tissue and sewn onto a small metallic cage. Once the catheter was guided across the failing valve, a balloon inside the
cage was inflated, expanding the valve, which began functioning immediately.
A group gathered outside a large observation window in the Cath Lab watched a live X-ray image displayed on a monitor next to the procedure table as the balloon suddenly expanded, pushing aside the old valve and implanting the new one. A small injection of contrast dye from the catheter showed on the X-ray image that the fluid was unable to pass through the closed valve – which meant the seal was tight and there were no leaks.
The catheter was withdrawn from the body, and a
little over an hour after the procedure began, a cardiac technologist turned to the observers watching through the window and gave a thumbs up. The new aortic valve was in place and functioning perfectly.
The patient was discharged home the following day, joining a growing legion of Cape Codders, as well as many patients from beyond the peninsula, who are alive and well today because they underwent a TAVR or one of the other cutting-edge procedures now offered by Cape Cod Hospital’s Interventional Cardiovascular Services program.
In fact, one Friday night in late summer of 2017,
Dr. Zelman and his colleagues performed a rare emergency TAVR procedure on a 71-year-old woman from Dennis with a badly diseased aortic valve, whose life hung in the balance. Her heart had stopped once in the emergency room, necessitating CPR, and then again a second time while the delicate operation was getting underway. The procedure – performed as the patient was receiving CPR – was successful and she recovered fully, leaving the hospital several days later.
Such a story would have been unthinkable in the not- so-distant past. Cape residents and vacationers who
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needed advanced cardiac care once had to cross the Bourne Bridge
or Sagamore Bridge and travel
to a teaching hospital in Boston. But over the past 25 years, Cape Cod Hospital has built a cardiac program that conducts ground- breaking research and offers patient care that ranks among the best in the United States.
“I don’t think you’ll find another hospital in the country, maybe
not even in the world, that has transformed itself in this way, over a relatively short period of time,” said Dr. Zelman.
HOW IT STARTED
When Dr. Zelman arrived at Cape Cod Hospital in 1990, the world of cardiovascular medicine was in the midst of a revolution. Large teaching hospitals in the United States and other countries with cardiac catheterization facilities allowed doctors to diagnose and treat diseases of the heart, such as narrowed coronary arteries – the leading cause of heart attacks – as well as defects of the heart muscle and valves.
In a cardiac catheterization procedure, a doctor inserts a catheter into a blood vessel (usually the femoral artery in the groin
or more recently the small radial artery in the wrist), and then maneuvers the device through the body’s vasculature until it reaches the heart. Doctors can use this versatile technology to perform various tests and treatments, such as taking a digital video X-ray (known as a coronary angiogram) to determine if a buildup of cholesterol and other substances may be impeding blood flow to the heart muscle.
If a blockage is discovered, a tiny balloon attached to the tip of a catheter can be guided to that spot and inflated to reopen the artery.


This procedure is called coronary angioplasty. Typically doctors will then insert a mesh tube known
as a stent via this same catheter
to serve as a scaffold, keeping the artery open more permanently. In the early 1990s, these and other advances in the treatment of heart disease had not yet reached community hospital centers.
“We didn’t have a cardiac cath lab, we didn’t have a cardiac surgeon or cardiac operating room, and therefore we didn’t have the ability to perform angioplasty or insert stents,” said Dr. Zelman.
Patients who came to Cape Cod Hospital or Falmouth Hospital requiring advanced cardiac care were referred off-Cape. A year before Dr. Zelman’s arrival, the hospital sent well over 500 patients to teaching hospitals in Boston
for cardiac catheterization. But other community hospitals in Massachusetts were referring heart patients to Boston, too. That high volume meant patients needing prompt attention often had to wait many days for a hospital bed to become available.
“Many of those patients didn’t survive the waiting,” said Dr. Zelman.
People who suffered heart attacks during that era were often treated with drugs designed to dissolve blockages in the coronary arteries that cut off blood flow to the
heart. These drugs, known as thrombolytic or “clot-busting” agents, were a breakthrough when they were introduced in the 1980s and have saved many lives over the years. However, clot-busting drugs with their significant potential side effects, such as internal bleeding, could be utilized in less than
half of patients. And soon after
Dr. Zelman’s arrival at the hospital, research confirmed there was a better way to treat heart attacks.
THE PROGRAM GREW
In 1993, a large study published
in the New England Journal of Medicine demonstrated that heart attack victims who were treated with emergency angioplasty were more likely to survive and less likely to experience severe side effects than similar patients treated with clot-busting drugs. Dr. Zelman learned that some community
hospitals in other states, including New Hampshire, had begun treating heart attack victims with emergency angioplasty and stents, with impressive results.
Determined to bring this life-saving therapy to Cape Cod, Dr. Zelman chose to undertake an additional fellowship at Brigham and
Women’s Hospital in Boston, where he studied angioplasty and other aspects of interventional cardiovascular medicine. He
also completed a fellowship in interventional vascular medicine at St. Elizabeth’s Medical Center in Boston.
In 1994, cardiologist Lawrence McAuliffe, MD, FACC, who
was chief of cardiac services at that time, and other colleagues at Cape Cod Hospital, helped launch a new program that brought a mobile catheterization lab to the Hyannis hospital
and Falmouth Hospital once a week. Two years later, through Dr. McAuliffe’s efforts and with the support of hospital administration, the hospital built and unveiled a true cardiac
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“We didn’t have a cardiac cath lab, we didn’t have a cardiac surgeon or cardiac operating room, and therefore we didn’t have the ability to perform angioplasty or insert stents.”
- Richard Zelman, MD, FACC
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catheterization lab. (The facility has now grown to include a
suite of labs, with a fifth procedure room equipped with state-of- the-art equipment, added in December 2017.)
During this time, though, doctors at the hospital were only able to
use this powerful technology for
the purpose of diagnosing heart disease; patients still had to go off- Cape to have blocked arteries and other cardiac conditions treated in a cath lab. Massachusetts regulations only permitted hospitals to perform elective and emergency angioplasty if the institution had a cardiac surgical program on-site as backup, in case a problem occurred with
the minimally invasive procedure. At the time, Cape Cod Hospital did not have the ability to offer cardiac surgical procedures.
In 1995, Dr. Zelman and several doctors from other community hospitals in Massachusetts began lobbying the state Legislature with the goal of changing this regulation and allowing medical centers without on-site cardiac surgery to perform emergency angioplasty. In the meantime, Dr. Zelman found
a way to provide the important procedure to some patients
anyway, by enlisting the hospital in a randomized clinical trial run by researchers at Johns Hopkins University. The purpose of the study was to test whether hospitals without on-site cardiac surgery could safely perform balloon angioplasty and stenting in men and women who were suffering heart attacks. Patients included in the trial were randomly chosen
to receive either angioplasty or clot-busting drugs.
In the late 1990s, Dr. Zelman began working closely with interventional radiologist Philip Dombrowski, MD, who had arrived at Cape
Cod Hospital a few years earlier. Interventional radiologists use catheterization and other minimally invasive techniques to diagnose
and treat a wide variety of diseases. Dr. Dombrowski had previously worked at Falmouth Hospital
and traveled off-Cape to perform interventional radiology procedures at hospitals along the South Shore, sometimes carrying his catheters and other tools of his trade along in a ski bag.
The two doctors, along with various colleagues, began conducting research together, including
their pioneering work on the use
of angioplasty and stents as an alternative to open surgery in
the treatment of blockages in the carotid arteries in the neck. These blockages are a frequent cause
of stroke and transient ischemic attacks (TIAs, or mini strokes).
“We wanted to bring the ability to the Cape to treat patients who were having TIAs or strokes, or were at risk for them, with carotid stents,” said Dr. Dombrowski.
They also began using innovative approaches to treat other vascular problems, such as blood clots
in the legs and renal vascular hypertension, which is high blood pressure caused by blockages in the arteries to the kidneys.
A PIVOTAL MOMENT
One day in 1998 would prove
to be a pivotal moment in the transformation of the cardiac services program at Cape Cod Hospital. A 61-year-old Harwich woman named Barbara Galvin suffered a heart attack and was rushed to the hospital’s emergency room. Mrs. Galvin was a candidate for emergency angioplasty, but only as part of the Johns Hopkins-based study, which meant she would be entered into the computer program
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that randomly assigned patients to receive either angioplasty or clot- busting drugs. The system assigned Mrs. Galvin to the latter group.
Dr. Zelman administered clot- busting therapy to Mrs. Galvin; but as time passed, it became clear that the medication wasn’t dissolving the blockage in her coronary artery, and her condition worsened dramatically. She went into cardiac arrest several times, requiring defibrillation to “shock” her heart and stop it from beating erratically.
According to the rules of the study, a patient who didn’t respond to thrombolytic drugs was to be transported by air to a teaching
hospital in Boston equipped with full cardiac surgery for further care. But Dr. Zelman knew his patient was desperately ill and wouldn’t make it to the helicopter pad.
He was in a quandary: Administering balloon angioplasty could save Mrs. Galvin’s life –
but it would also break the rules
of the study and violate state regulations, potentially resulting in a severe penalty.
Dr. Zelman contacted several colleagues for advice on what to do and ultimately made up his mind to perform balloon angioplasty
on Mrs. Galvin, who was now in a coma. Within seconds of removing
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the blockage that had completely closed a major coronary artery, blood flow to Mrs. Galvin’s heart was restored. Four days later, she awoke from her coma with only minimal nerve damage in one leg, and would live another 17 years before passing away at
age 78 in 2016.
In 1999, the NBC news show Dateline aired a segment about Mrs. Galvin’s case. Meanwhile, the hospital had enrolled hundreds
of patients in the Hopkins trial, with excellent results. In response
to Mrs. Galvin’s dramatic story and Cape Cod Hospital’s growing successful track record, the Commonwealth of Massachusetts granted the hospital special permission to perform emergency angioplasty and stenting, despite not having cardiac surgery on-site.
“Now, emergency angioplasty [for heart attack patients] in hospitals like ours is the standard of care throughout the United States,” said Dr. Zelman, “and the way most patients in this country are treated.”


THE PROGRAM TAKES OFF
In the subsequent years, Cape Cod Hospital’s growing reputation for excellence in cardiac care made it possible to recruit top physicians, which helped to expand the roster of services available to patients. Soon, for example, the Cardiac Services program expanded
to include electrophysiology procedures, which diagnose and correct arrhythmias, or abnormal heart rhythms.
Between 1994 and 2000, efforts
by Dr. McAuliffe and the hospital administration to start a cardiac surgery program continued. In 2000, CCH was awarded one of three new open heart programs in the Commonwealth (the first non- tertiary care program to be licensed in over 25 years).
Importantly, the hospital forged a partnership with Brigham and Women’s Hospital in Boston to
bring cardiac surgeons on staff
in 2001. This new relationship meant the hospital met the state’s requirements for providing elective angioplasty. Cape Cod Hospital began offering the latter in 2002, meaning patients in need of this highly effective treatment no
longer had to travel to Boston. The program now includes two cardiac surgeons who remain affiliated with Brigham and Women’s Hospital.
Today, the variety of lifesaving procedures offered at Cape
Cod Hospital’s Interventional Cardiovascular Services program rivals that of any academic medical center.
Caring for patients who undergo these complex procedures requires a commitment to teamwork amongst not only cardiologists and cardiac surgeons, but also anesthesiologists, perfusionists, nurses, physician assistants, and
expert technologists. Moreover, Cape Cod Hospital was one of the first community medical centers
in the United States to create a Cardiology Hospitalist program (see page 31), which features a team of cardiologists who focus solely on administering care to inpatients.
That spirit of collaboration creates an environment where men and women with ailing hearts on Cape Cod can receive superior care, just a short drive away.
“The concept of the Heart Team
is to always try to think first
and foremost: What’s best for
the patient? Which procedure offers him or her the best long- term results with as little risk as possible?” said Dr. Dombrowski. “Everyone brings their expertise to the table. I think that’s where what we offer is so unique.” | TJ
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Today, the variety of lifesaving procedures offered at
Cape Cod Hospital’s Interventional Cardiovascular Services program rivals that of any academic medical center.
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OPEN HEART SURGERY – WITHOUT THE ‘OPEN’
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Transcatheter aortic valve replacement offers some heart valve patients a less invasive option.
By Timothy Gower
John Pitt loves a good, long walk, but the retired teacher was surprised to find he was running out of breath as he strolled the hilly streets of San Diego while vacationing in the spring of 2017. Upon returning home to Chatham, Pitt, 83, saw his cardiologist at Cape Cod Hospital, Lawrence McAuliffe, MD, FACC.
“You’re ready for a new heart valve,” said Dr. McAuliffe, who referred Pitt to his colleagues, interventional cardiologist Richard Zelman, MD, FACC, and cardiac surgeons Paul Pirundini, MD, and Dan Loberman, MD, to be evaluated for a transcatheter aortic valve replacement (TAVR) procedure.
Specifically, Pitt needed a new aortic valve. As the heart beats, the aortic valve opens to release blood into the aorta, the largest blood vessel in the body, and then closes again to keep blood from seeping backwards. From the aorta, blood travels through a network of blood vessels to nourish the body’s tissues. With aortic stenosis, that critically important valve doesn’t open wide enough, which restricts the volume of blood the heart pumps.
The aortic valve opens to release blood into the aorta and then closes again to keep blood from seeping backwards into the heart.
Roughly 5 to 8 percent of adults over the age of 75 have aortic stenosis. Some are born with a predisposition
to the condition, though calcium deposits and aging can cause even normal valves to narrow. Patients with aortic valve stenosis may remain asymptomatic and not have any ill effects for many years, but ultimately their lives are dramatically changed by the condition, which results in progressive fatigue, shortness of breath, dizziness, chest pain and other symptoms. Left untreated, aortic stenosis is ultimately progressive
and fatal.
Fortunately, for many decades doctors have been able to successfully replace a defective aortic valve with a prosthetic version. However, the traditional technique for replacing an aortic valve involves open surgery, which requires an incision in the chest and separation of the breastbone. Open heart surgery is not an option for roughly one-third of patients with aortic stenosis, due to advanced age or the presence of other serious health conditions. Moreover, recovering from open surgery can take three to six months, and some patients who need the procedure may decide they aren’t willing to give up so much precious time.
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In the past, patients with symptomatic aortic stenosis who couldn’t or wouldn’t undergo open surgery
had few options besides taking medication to ease symptoms. However, many are now candidates for TAVR, which the Food and Drug Administration (FDA) has approved for use in patients deemed by
a hospital heart team to be at intermediate, high or extreme risk for serious complications with
open surgery.
In a TAVR procedure, a doctor typically obtains access to the vasculature by inserting a small needle into the femoral artery in the upper leg, though other entry (alternative access) points may be used if necessary. Through this access, the doctor then threads a catheter tube through the blood vessels until it reaches the heart, using digital X-ray and ultrasound imaging to guide
the device’s movement. When the catheter holding the new valve reaches the diseased native valve, a balloon at the tip is inflated, deploying the TAVR valve, which instantly becomes functional.
Cape Cod Hospital has provided TAVR services since 2015, and about 150 men and women will receive new aortic valves through the procedure this year.
“Most patients are back to full activities in a few days,” said Dr. Zelman. “The major difficulty we have is keeping them from doing too much, rather than
the opposite. They feel so much better than they have in years.”
Pitt underwent a TAVR procedure in June of 2017 and was up and around, then on his way home, within a couple days. Remarkably, he and his wife, Susan, were on a plane two weeks later for a Scandinavian vacation with their daughter, Darlene.
“I did a lot of walking in Oslo and Stockholm, and I never had a problem,” said Pitt.
Susan couldn’t believe the trip happened at all. “We never stopped marveling that we did it,” she said.
Back on the Cape, the Pitts take long walks three or four times a week.
“The whole experience has been amazing,” said John Pitt, who expressed deep gratitude to Dr. Zelman and his staff. “They renewed my life.” | TJ
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By Timothy Gower
Similar to the transcatheter aortic valve replacement (TAVR) procedure, transcatheter mitral valve repair (TMVR) is a minimally invasive procedure that can obviate the need for open heart surgery in certain high-risk patient populations.
As blood travels through the heart, it moves from
an upper chamber called the left atrium to a lower chamber, the left ventricle, by passing through the mitral valve. A healthy mitral valve has leaflets that open to allow the ventricle to fill and then close tightly in order to prevent leakage of blood backward into
the pulmonary circulation. However, some people are born with defective mitral valves, while in others illness or wear and tear can seriously impair the function of the valve leaflets. Abnormal leakage of this valve may be due primarily to abnormalities of the valve leaflets themselves or secondarily to issues related most often to damage suffered by the left ventricular muscle, usually as a result of coronary artery disease.
Although diseased mitral valves don’t always cause symptoms, for many patients these conditions can have serious consequences. If blood builds up in the left atrium and the heart has to work harder to pump adequate blood out to the body, a patient may develop congestive heart failure, in which fluid backs up in the lungs, legs and elsewhere, resulting in cough, shortness of breath, swelling and other symptoms. The symptoms of mitral valve disease can be alleviated to some degree
by medications. But for many patients with a more severe degree of leakage, medical therapy is not enough.
“As a result, we have many patients living on multiple medications who, despite this, are chronically readmitted to the hospital because of congestive heart failure,” said Richard Zelman, MD, FACC, chief of inpatient cardiology at Cape Cod Healthcare. “These patients will often experience shortness of breath and other symptoms with the slightest exertion, or even when sitting still or attempting to sleep.”
Replacement or repair of a faulty mitral valve is possible with open surgery but, since 2017, Cape Cod Hospital has been able to provide TMVR, a minimally invasive procedure which repairs the faulty valve using catheter techniques. The FDA has approved a TMVR device known as the MitraClip® for patients who have severe symptoms from degenerative mitral regurgitation and are too sick to withstand the rigors of open surgery. This determination is made by a heart team comprised of interventional cardiologists, cardiac surgeons, cardiac anesthesiologists and cardiac imaging specialists.
The procedure is performed under general anesthesia and often can be completed in under two hours. Dr. Zelman and fellow interventional cardiologist Alanna Coolong, MD, insert a special catheter through a small needle hole into the femoral vein in the upper leg. The catheter is then guided by an advanced 3-D imaging
––––[ Program Evolution ]––––
A MINIMALLY INVASIVE WAY TO AVOID CONGESTIVE HEART FAILURE
–––––––––
The transcatheter mitral valve repair uses the MitraClip® device to prevent mitral regurgitation, and avoid serious consequences.
The MitraClip® device is a small clip roughly the size of a dime that is attached to the mitral valve. When inserted, the clip closes the valve more completely to help restore normal blood flow through the heart.


––––[ Program Evolution ]––––
technique (transesophageal ultrasound) across the wall that separates the right from left atrium of the heart and between the two leaflets that comprise the mitral valve. The doctors can then attach between one and three MitraClip devices to the faulty valve leaflets, resulting in the dramatic reduction of leakage. Recovery time from the procedure is often just one or two days in the hospital, after which patients can soon resume normal daily activities.
A 2011 study in the New England Journal of Medicine found that while open surgery to repair or replace a leaking mitral valve was somewhat more effective than TMVR for reducing mitral regurgitation, patients who underwent the latter procedure had far fewer adverse effects and reported improved quality of life far faster. After patients have the TMVR procedure, according to Dr. Zelman, “The next time we see them is generally in the outpatient valve clinic one to two weeks later. It is astounding how much improvement has occurred in such a short period of time, with many patients resuming an independent lifestyle and driving themselves to clinic. They are often unrecognizable compared to how frail and limited they appeared prior to the procedure.”
Currently, the MitraClip is approved by the FDA only for treating degenerative mitral
valve disease in patients with moderately severe to severely leaking valves and symptoms of congestive heart failure. These patients must
be deemed high-risk for surgical repair by a multidisciplinary heart team specializing in the care of patients with valvular heart disease, like the team at Cape Cod Hospital. | TJ
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––––[ Surgery ]––––
STILL THE GOLD STANDARD
–––––––––
Open heart surgery remains the go-to procedure for some cardiac conditions.
By Bill O’Neill
Unlike many areas of cardiac care, some of the more fundamental aspects of open heart surgery have remained the same over the past few decades. It can still be the gold standard for treating certain conditions, according to Cape Cod Hospital chief cardiac surgeon Paul Pirundini, MD.
“Coronary artery bypass surgery, for example, can be performed in ways that are fairly similar to how it was done 20 years ago,” he said. “Certainly, our knowledge base has improved over this time. We have a better understanding of what conduits to use in certain situations, and we are generally better at protecting the heart during the bypass run.”
Of note, the types of patients undergoing surgery today are often very different from those of 20 or 30 years ago
“We tend not to see the more straightforward patients who require one- or two-vessel bypass operations of years ago, as those patients typically undergo stenting for single or double vessel disease,” he said, referring to a minimally invasive procedure whereby a wire mesh device is threaded through a narrow catheter inserted in the groin and into the blocked coronary vessel, in order to restore blood flow. “We see folks who are further advanced with respect to their disease state. We see more patients who have already had prior cardiac procedures; they tend to be older, and the disease states can be a little more complicated.”
Dr. Pirundini performs what he called “a wide range of cardiac surgical procedures – coronary bypass, aortic valve surgery and mitral valve surgery. I do a fair number of ascending aortic procedures as well, including aortic dissections and aneurysms.”
After completing two residencies, one in general surgery at Waterbury Hospital in Connecticut and the other in cardiothoracic surgery at the University of Medicine and Dentistry of New Jersey, Dr. Pirundini completed his fellowship training in adult cardiac surgery at Brigham and Women’s Hospital (BWH)
in Boston.
“I finished at the Brigham on June 30, 2004, and started at Cape Cod Hospital on July 1, 2004 – 12 hours after I finished there.”
CHIEF OF CARDIAC SURGERY
Dr. Pirundini was named chief of Cardiac Surgery Services at Cape Cod Hospital in 2013. He and Dan Loberman, MD, who also trained at Brigham and Women’s Hospital, are the two cardiac surgeons on staff at Cape Cod Hospital.
The Cardiac Surgery program at Cape Cod Hospital is affiliated with Brigham and Women’s Hospital (BWH), which is “a very good collaboration,” according to Dr. Pirundini. One of the things that attracted him to the Cape was the team approach to cardiac care.
“We have the ability to discuss cases with our colleagues at BWH as the situation dictates. Additionally, the majority of patients encountered are discussed with the cardiologists at CCH,” he said.
Over the last few years, there has been a collaborative approach with the interventional cardiologists, including Richard Zelman, MD, FACC; Alanna Coolong, MD; and David Leeman, MD, and their team of physician assistants, cardiac technologists, nurses and others, Dr. Pirundini noted. The cardiac surgeons also work closely with the interventional cardiologists


––––[ Surgery ]––––
Paul A. Pirundini, MD, chief of cardiac surgery, Cape Cod Healthcare


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––––[ Surgery ]––––
on new minimally invasive procedures like transcatheter aortic valve replacements and transcatheter mitral valve repairs.
AMONG THE BEST IN
THE NORTHEAST
Dr. Pirundini considers himself “very lucky” to be working with the heart team at Cape Cod Hospital.
“First and foremost I have a great partner,” he said of Dr. Loberman. “He is a highly experienced, excellent cardiac surgeon.”
Dr. Loberman joined the team in December 2013, after finishing his training.
“We have an amazing group of individuals who provide cardiac anesthesia at CCH, all of whom are on staff at BWH. Many of these physicians I’ve known and worked with since training. I often think of how fortunate we are that they are here,” Dr. Pirundini said.
The team also includes a “great group” of perfusionists, who


operate the heart-lung machine used during cardiac surgery.
In addition, there are highly experienced mid-level providers who help provide expert around- the-clock care, both in and out of the operating room, he said.
“Last but certainly not least is a group of caring, devoted nurses who take wonderful care of our patients,” he added. With the current team, “Cape Cod Hospital is capable of handling just about any kind of cardiac surgical case.”
“YOU DON’T COMPROMISE”
Dr. Pirundini credits many mentors with helping shape his career and the way he approaches cardiac surgery. The best bit of advice he’s ever received?
“I remember one old vascular surgeon, and he had this saying: ‘Follow the rules and you don’t go wrong.’ What he meant by it was, you do it exactly the way you were taught and don’t try to recreate the wheel. Do what is safe and efficient.
I’ve often thought of that advice. There are certain things you do, in order to do surgery well – and you don’t compromise.” | TJ
––––[ Surgery ]––––
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––––[ Surgery ]––––
Dan Loberman, MD, director of minimally invasive heart surgery, Cape Cod Healthcare


THIS PATIENT IS DOING BETTER NOW THAN 10 YEARS AGO
–––––––––
Mini mitral valve surgery restored Sturgis St. Peter’s health and vigor.
By Bill O’Neill
Sturgis St. Peter will always remember the day a cardiac surgeon at Cape Cod Hospital told him about his planned course of treatment for his heart problem.
“Dr. Dan Loberman came in and said, ‘We’ll take good care of you. We’ll do this procedure that’s called the mini mitral valve surgery. Instead of doing a midline incision, we just make a small cut underneath your right breast and use some micro tools to repair
the valve.’”
St. Peter’s response: “That’s cool.”
St. Peter, 67, of Barnstable, can talk about it in a light- hearted way now, but when he had the surgery in May 2016, he was in dire shape. He had a torn mitral valve, which had left him feeling weak and sick for months.
BETTER EXPOSURE
Mini mitral valve patients typically have a shorter length of stay in the hospital, versus a five- to seven- day stay and a six- to 12-week recovery for median sternotomy patients. Cosmetic results are also better.
“Women can wear a bathing suit, and no one will ever know that they had mitral valve surgery,” Dr. Loberman said.
There’s an advantage for the surgeon, as well, because the approach to the mitral valve through the minimally invasive incision gives them a better view of the mitral valve.
“The mitral valve lies in such a way that when you go from the right side of the chest, you just fall on it and you don’t look at it from above, as happens with mid- sternotomy patients,” he said. “Whoever reads surgical books for any reason, one of the main phrases you see is that the thing that facilitates good surgery
is exposure.”
Dr. Loberman and his team have performed more than 100 mitral valve surgeries at Cape Cod Hospital over the past three years, including about 50 minimally invasive mitral valve procedures, mostly repairs.
“We have had very good results as demonstrated by one-year post-operative echocardiograms to look at the valve function. When you repair a 50-year-old’s leaky mitral valve, you’re moving from one survival curve to the general population survival curve.
“It’s no longer a new procedure. It’s something we can do any day, at any time, for whatever patient comes in needing the procedure.”
The mitral valve is the “inflow valve” for the left side
of the heart. It can need surgical repair or replacement because of stenosis (narrowing) or regurgitation (leakage). Traditional mitral valve surgery requires a median sternotomy, an incision of six to eight inches
in the middle of the chest. In minimally invasive mitral valve surgery, an incision of two to three inches is made in the right side of the chest.
Mini mitral valve surgery has a number of advantages, according to Dr. Loberman. Approaching through a mini thoracotomy instead of a median sternotomy benefits patients in three main ways.
“It has been proven that approaching through a mini right thoracotomy instead of a median sternotomy has saved patients from receiving extra blood products, shortened length of stay post-operatively and reduced the pain level after surgery,” he said.
––––[ Surgery ]––––
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It is, however, still heart surgery, which means that the operative risks are there, and should be discussed and clarified prior to proceeding with surgery. Prudent patient selection is crucial.
AFFILIATION AND TRAINING
The Cape Cod Hospital Cardiac Surgery program is part of the Cape Cod Healthcare Heart & Vascular Institute, a partnership between
the healthcare organization and cardiovascular physician specialists on Cape Cod. The Cape Cod Hospital Cardiac Surgery program has been affiliated with Brigham and Women’s Hospital in Boston since the program started in 2001. The partnership has allowed the Hyannis hospital to expand its cardiac surgery services to include the latest procedures.
“I was lucky to have my old boss, my professor in Israel, who was Dr. Alain Carpentier’s student. Mitral valve repairs were his little baby. I used to watch him operate and I think I saw him do 500 procedures before I laid a hand on a patient.”
“The heart is a three-dimensional structure, and you really need to know the anatomy to know the implications of every movement you make,” he stressed.
When Dr. Loberman wanted to add the minimally invasive technique
to his surgical repertoire, he took his surgical team to Miami three times to study with Joseph Lamelas, MD, FACS, an expert in minimally invasive heart surgery, who is now affiliated with Baylor College of Medicine in Houston, Texas.
“Knowing that this is not a one- man show, I wanted to train my team as well,” Dr. Loberman said. “With that in mind, I took my perfusionist and physician assistants with me to see how Dr. Lamelas’ team works.”
WHICH PATIENTS ARE CHOSEN
The best candidates for mini mitral valve surgery are those whose heart structure is not yet too
frail or damaged.
“We want to identify patients when they are not yet symptomatic;
the patients who have not yet
developed the sequalae or the natural history of mitral valve leakage, such as atrial fibrillation, embolic events or congestive heart failure,” said Dr. Loberman. “The best results are with patients who don’t have symptoms yet.”
Patients with mitral valve regurgitation or leakage have a heart murmur, he said.
“That shows up in an echocardiogram or in a simple checkup in a cardiologist’s office
or in a primary care physician’s office,” he said. “Once you identify a murmur, you need to define it better with an echocardiogram. If you
find mitral valve regurgitation, that patient needs to be monitored. If the regurgitation gets to be severe,
it might be treated surgically.”
The echocardiogram results indicate whether repair or replacement is indicated. The assessment process of the heart structures then begins, and the surgeon decides how to go about the repair, he said.
Replacement of mitral valves can be mechanical (carbon fiber), which last for a lifetime but may
––––[ Surgery ]––––


––––[ Surgery ]––––
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19
A small incision and the use of rib spreaders Mitral valve repair/replacement is an approach facilitates access in a minimally invasive technique. that can be performed in a small, 5-6 cm incision.
Illustrations: Medtronic Academia
require long-term use of Coumadin (a blood thinner), or biological (typically from a pig’s or horse’s pericardium), which last for 10 years, possibly 20.
“After the surgery, sometimes patients feel better and stronger. They breathe better,” said
Dr. Loberman.
In some cases, if there were no clinical symptoms before surgery,
there will not be any change in
a patient’s general feeling, but multiple studies have demonstrated that patients’ long-term health benefits from the procedure.
“With the minimally invasive mitral valve procedure, if the patient is recovering without any complications, after two to three weeks he can be back to work, even if it’s a physically demanding job,” he said.
St. Peter, who is a building contractor, is the first to tell you he made an impressive recovery from his mini mitral valve surgery.
“I felt so good that about two months after the surgery, I went out and bought a 70-mile-per-hour Jet Ski,” he said. “I’ve been terrorizing people ever since. I still do my high-speed go-kart racing. I’m still very physical, swinging a hammer. I’m doing better now than I did 10 years ago.” | TJ


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––––[ Electrophysiology ]––––
A ‘VERY ATTRACTIVE’ ALTERNATIVE TO TAKING BLOOD THINNERS
–––––––––
The new WatchmanTM device can effectively treat AFib in some patients.
By Susan Moeller
Contributing author, Timothy Gower
A cardiac procedure available at Cape Cod Hospital allows some patients with a dangerous type of heart arrhythmia to give up blood thinners without increasing their risk of stroke.
The procedure, left atrial appendage closure (LAAC), done with a device called the WatchmanTM, has been provided to patients on Cape Cod since 2016. The device was approved by the U.S. Food and Drug Administration in March 2015 for patients who have an arrhythmia known as atrial fibrillation, or AFib, that is not related to issues with their heart valves.
While not yet approved for all AFib patients, the Watchman allows some to avoid or give up blood thinners that, while effective at preventing stroke, can cause significant complications.
“I think it will be widespread; I think it’s a very attractive alternative to taking oral anticoagulants,” said Peter Friedman, MD, PhD, FACC, FHRS, a Cape Cod Healthcare cardiac electrophysiologist who performs the Watchman implant procedure at Cape Cod Hospital (CCH).
The device is about the diameter of a quarter and looks like a tiny umbrella. Doctors use it to block off a small area of the heart – the left atrial appendage, or LAA – where blood clots are likely to form, dislodge and lead to an ischemic stroke – a stroke caused by a blockage in a blood vessel (as opposed to a hemorrhagic stroke, which occurs when a blood vessel bursts).
WHAT IS AFIB?
AFib is caused by a disorganization of the electrical impulses that regulate the beating of the heart. The heart has four chambers – the two atria on top and the
two ventricles on the bottom. When the heart rhythm is normal, all of the cells in the two atria are activated simultaneously, which causes them to contract. The electrical impulse in the upper chambers is then transmitted over a conducting system of cables to the ventricles, causing them to contract and pump blood throughout the body.
In patients with AFib, those electrical impulses in the atria are chaotic and random.
“The cells are not being activated together, and so
the two atria, instead of contracting and pumping blood into the lower chambers, are just quivering,” Dr. Friedman said. “There’s no organized activity. The lower chambers are beating normally, but they’re beating faster than they should, and they’re irregular because they are being bombarded by impulses from above.”
Because the blood isn’t being efficiently pumped, it
can pool, stagnate and clot in the nooks and crannies of the heart, such as the LAA, a small sack off the left atrium that is a half-inch to two inches long. When
a clot breaks loose and travels to the brain, it causes
a stroke. Stroke is the most common and devastating complication of AFib, and it’s usually a large stroke that causes serious impairment or even death, Dr. Friedman said. People with AFib have a fivefold increased risk for ischemic strokes compared to the general population.
Ninety percent of clots causing strokes in patients whose AFib is not related to a valve problem, arise from the LAA, he said.
To reduce the risk of ischemic strokes, physicians prescribe blood thinners, such as warfarin (Coumadin) or newer drugs known as novel oral anticoagulants


––––[ Electrophysiology ]––––
Peter Friedman, MD, PhD, FACC, FHRS,
cardiac electrophysiologist, Cape Cod Healthcare


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––––[ Electrophysiology ]––––
(NOACs.) However, these drugs increase the risk for serious bleeding, including strokes caused by brain hemorrhages, so up to 50 percent of AFib patients cannot or will not take blood thinners. Some can’t tolerate the drugs due to other health conditions, while others with AFib are unwilling to take blood thinners because they are concerned that a cut or trauma while on the job or engaging in a favorite activity such as skiing could expose them to severe and possibly fatal bleeding.
“Whenever you give a blood thinner, you have to weigh the benefit to be gained in terms of preventing stroke versus the risk of having bleeding,” Dr. Friedman said.
The Watchman has been available in Europe since 2005. It was approved here in the U.S. after the FDA found
it to be “non-inferior” to warfarin
in preventing stroke, systemic embolism or cardiovascular death. A survey of Watchman implants reported in the Journal of American College of Cardiology last year
found that of the 3,822 completed in the United States following FDA approval, 3,653 were successful –
or 95.6 percent. The survey found that complication risks in the first year of widespread use were even lower than the rates reported in clinical trials of the Watchman, even though it was a new device to many physicians.
“This is a significant game changer,” said Richard Zelman, MD, FACC, chief of inpatient cardiology for Cape Cod Healthcare, who also performs the Watchman procedure. “Patients who are not candidates for long-term blood thinners now


have the opportunity to be treated with a catheter procedure that can be performed in under an hour with great safety and efficacy.”
patients with scores of 2 or higher get the medication unless there is some compelling reason they can’t tolerate it, he said. Even if doctors perform ablation (a catheterization procedure) to cauterize (radiofrequency ablation) or freeze (cryoablation) the misfiring cells that provoke AFib, patients may still need anti-coagulants.
The Watchman is now an option
for patients who have a compelling reason for not tolerating anti- coagulants long-term, are at a
high risk of stroke, and have a CHA2DS2-VASc score of 3 or greater, Dr. Friedman said. Medicare has specific guidelines for patients to be eligible for Watchman procedures, although there is not yet universal coverage by private insurance.
THE WATCHMAN PROCEDURE
A Watchman is inserted under general anesthesia and can take under an hour, Dr. Friedman
said. Working together with Dr. Zelman and a team that includes cardiac imaging specialist Tendoh Timoh, MD, FACC; a cardiac anesthesiologist; and several Cath Lab nurses and technologists, a catheter is inserted through the femoral vein in the upper leg and guided through the vascular system into the left atrium. The Watchman is then deployed from the tip of the catheter and opened, creating a dam to block blood from passing into the LAA. Eventually, heart tissue grows over the device, permanently sealing off the LAA.
Patients usually stay in the hospital for 24 hours. If all goes well, they may be off warfarin as soon as 45 days after the procedure.
The Watchman has worked for David Howes, 76, of East Dennis, the first patient at Cape Cod Hospital to receive the implant. Dr. Friedman had treated Howes’ AFib with ablation but the condition returned and he was put back
on an anticoagulant. He had the Watchman surgery in June 2016 and was off blood thinners by the fall.
“There was no pain, no strain, never felt a thing,” Howes said. He was reassured when he met the surgical team. “They were a sharp bunch, the whole bunch of them,” he said.
The only medications Howes now takes are an aspirin a day and a drug to regulate his heartbeat.
Dr. Friedman believes doctors have an increasing appreciation for the risk of stroke in patients with AFib, and eventually the Watchman might well be a solution for a broader range of patients.
“As time goes on and other
groups of patients are studied, the Watchman will likely turn out to be a good alternative to anticoagulation in many other clinical scenarios.
But that requires information from clinical trials that have not yet been completed,” he said. | TJ
HOW’S YOUR CHA DS -VASC
SCORE? 2 2
When assessing patients, doctors
use a risk schematic called the
CHA DS -VASc, Dr. Friedman said. 22
Think of the letters like a spelling mnemonic:
• C = congestive heart failure (1 point)
• H = hypertension (1 point)
• A = age 65-74 (1 point); age >75 (2 points)
• D = diabetes (1 point)
• S = previous stroke or TIA (transient ischemic attack) (2 points)
• VA = vascular disease (1 point)
• Sc = sex category (1 point – female)
Each letter or risk category is assigned a score. A prior stroke or being over age 75, for example, each earns a patient two points. Diabetes, being over 65 or being female each counts for one point. So, a 68-year- old female with diabetes would have a CHA DS -VASc score of 3,
22
meaning she would have an annual
risk of stroke between 3 percent and 6 percent – “not a small number,” according to Dr. Friedman.
Patients with CHA2DS2-VASc scores of zero are not usually given blood thinners, he said. And doctors vary on whether they treat patients with scores of 1 with anticoagulants. But
––––[ Electrophysiology ]––––
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A PACEMAKER THE SIZE OF A VITAMIN CAPSULE
–––––––––
The MicraTM TPS is a wireless device inserted directly into the heart, alleviating some forms of arrhythmia.
By Susan Moeller
Paul Schneekloth of East Dennis spent his career as a technician for AT&T, had three children, played in a softball league and, in his youth, semi-pro hockey. And then, at the age of 71, he was tired all the time.
“I’d get up in the morning and get dressed and I’d just be exhausted from getting dressed,” he said.
Schneekloth learned the electrical impulses of his heart were misfiring and he needed a pacemaker. In April of 2017, he was the first recipient of a new, state-of-the-art wireless pacemaker device called MicraTM TPS at Cape Cod Hospital.
The MicraTM Transcatheter Pacing System is a long name for a device that looks like a large vitamin capsule
with tines on the end. Unlike current pacemakers that stimulate heartbeats via wires connected to the heart, it is inserted directly into the heart and doesn’t have wires or a separate battery.
It is suitable for some patients with a slow heart rhythm known as bradycardia, according to cardiac electrophysiologist Peter Friedman, MD, PhD, FACC, FHRS, who, by the fall of 2017, had implanted the devices in five patients at Cape Cod Hospital.
“For someone who only needs pacing in the lower chamber of the heart, this device is now a good alternative to the standard pacemaker,” Dr. Friedman said, holding one of the tiny pacemakers in the palm of his hand.
Everyone is born with a natural pacemaker: the sinus node. It creates the electrical impulses that trigger a heartbeat and sends them through the upper chambers of the heart, or atria, causing them to contract,
Dr. Friedman said. The impulses then are conducted
through a spot in the middle of the heart, the AV Node, that acts as a relay station. It delays the signal for a
brief moment and sends it through a cable-like muscle system called the bundle branches into the heart’s lower chambers, the ventricles, making them beat.
But just as the electrical system in your home can go haywire, so can the one in your heart.
“Some people as they get older develop a problem
with the sinus node,” Dr. Friedman said. “It becomes sluggish or unreliable, so they have a very slow heartbeat. Sometimes the heartbeat just stops for a few seconds and they run out of gas or they get lightheaded or they even faint.”
Patients can also develop problems in the AV node or in the conducting system. Pacemakers help by sending electrical impulses to the heart to restore the natural heart rate, by stimulating either a single chamber of the heart or both the upper and lower chambers.
The ideal candidate for the Micra TPS has “permanent” or constant atrial fibrillation, AV block and needs pacing in only one chamber – the right ventricle,
said Dr. Friedman. Patients who are candidates for a standard pacemaker, in whom, for a variety of reasons, the wires cannot be placed successfully, would also be good candidates for the leadless pacemaker. From two to four patients a week get pacemakers at Cape Cod Hospital and about 25 percent of them might qualify for the Micra TPS, he said.
THE MICRA TPS PROCEDURE
The Micra TPS is revolutionary in that it eliminates the battery, the wires and the need for the skin pocket that are required for a standard pacemaker.
––––[ Electrophysiology ]––––


During a standard pacemaker procedure, the physician makes an incision below the patient’s shoulder and, using X-ray, guides a wire down a vein and into
the right ventricle of the heart, Dr. Friedman said. Occasionally, a needle puncture is required to gain access, which, on rare occasions, can cause the lung
to collapse.
Once the wire is in good position, the doctor makes a pocket in the skin, inserts a flat battery about the size of a silver dollar in diameter, plugs in the wire from the heart, and stitches up the incision. The patient spends a night in the hospital.
“It’s a reliable device and it’s served us well for a long time,” said Dr. Friedman, who works with a team for the procedure that includes a radiology technician and a cardiology technician.
But there are issues with a standard pacemaker. Cosmetically, pacemaker surgery creates a scar and the device bulges in the upper chest. And about one in eight patients has complications, according to the New England Journal of Medicine.
The battery must be replaced every five to seven years by reopening the skin pocket, Dr. Friedman said. Because of scar tissue and less blood flow in the area, the risk of infection during replacement is higher than during the original procedure. And the wires are a weak link. They can malfunction or lose their insulation and send worthless impulses into muscle instead of the heart. If a wire needs to be replaced, the procedure is complicated and risky, Dr. Friedman said.
The Micra TPS pacemaker is guided to the right ventricle and attaches to the tissue.
In contrast, to implant the new Micra TPS pacemaker, the patient is sedated and then the physician makes a
tiny incision in the femoral vein in the upper part of the thigh. The device is attached to the tip of a long catheter which is inserted through the vein into the patient’s right ventricle. The physician pushes the device against the wall of the heart, allowing the tines to lodge into the tissue.
After testing to make sure the Micra TPS is secure and transmitting correctly, the doctor withdraws the delivery device. Pressure, or perhaps a stitch or two, stops the bleeding from the incision in the leg. The patient usually goes home the same day. There are no restrictions on movement or physical activity, and no post-operative chest X-ray is required. The patient is on antibiotics for a couple of days and might have to take them to prevent cross- infection from surgery or dental work, Dr. Friedman said.
The Micra TPS battery is likely to last 12 years and, if it loses power or fails, another one can be inserted next to it, Dr. Friedman said.
Researchers at the University of Oklahoma and other sites reported in a November 2015 issue of the New England Journal of Medicine on Micra TPS implants in 725 patients. The device was successfully implanted in 99.2 percent of the patients, and 96 percent of them had no major complications after six months.
Several months after receiving his new Micra TPS pacemaker, Schneekloth said he wasn’t even aware of the device, except in a good way.
“I’m 100 percent better,” he said. “I can cut the grass. I can’t push the lawn mower and cut the grass, but I can sit down on it. I can walk a lot further without getting tired.” | TJ
––––[ Electrophysiology ]––––
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25


––––[ Vascular Surgery ]––––
Philip J. Dombrowski, MD, medical director of interventional radiology, Cape Cod Healthcare


––––[ Vascular Surgery ]––––
LESS-INVASIVE ANEURYSM REPAIR
–––––––––
Relieving AAA symptoms, preventing rupture and prolonging life.
By Glenn Ritt
Albert Einstein, George C. Scott, Harvey Korman, King George II and Lucille Ball - all died from a condition known as abdominal aortic aneurysm, or AAA. It’s a quiet killer because in most instances there are no symptoms until it’s too late. In fact, 1.7 million people have AAA and an estimated 50,000 people undergo AAA repairs annually.
An aortic aneurysm is a bulge in the aorta, the largest blood vessel in the human body. A weak spot in the aortic wall causes this ballooning to occur. An AAA strikes in the portion of the aorta that passes through the abdomen, giving it the appearance of a golf ball stuck in a water hose.
The most worrisome aspect of AAA is that it can burst, leaking blood into the abdomen—a medical emergency that requires immediate treatment. Many victims don’t make it to a hospital in time, though. About 7,000 Americans die of AAAs each year.
AAA rupture is the 13th leading cause of death in men, in general, and is the 10th overall cause of death in men over age 65.
If and when an aneurysm bursts, only one in four people will survive long enough to reach surgery,
and then only half of those will have a positive outcome. A typical sufferer is a man 65 years of age or older, especially one who smokes, has hypertension, is obese, has emphysema or has a family history of AAA in the family. Men are five times more likely to suffer from the condition as women. However, AAAs
in women have a faster growth rate and a four times increased rupture rate.
The goals of treatment, whether open or endovascular, are to relieve symptoms (sudden-onset of unrelenting abdominal or back pain), prevent rupture and prolong life, noted Falmouth Hospital vascular surgeon Lindsey Marie Korepta, MD, RPVI.
Dr. Korepta is one of an expanding team of specialists at Falmouth Hospital and Cape Cod Hospital that are focusing on state-of-the-art endovascular aneurysm repair (EVAR) treatments. Dr. Korepta, who completed a specialized five-year vascular and endovascular surgery residency at Michigan State University, is the newest member of the team. Vascular surgeons Stephen Brooks, MD, FACS, RPVI and Daniel Gorin, MD, RVT, FACS, have been performing advanced EVARs on Cape Cod for many years.
Both surgeons work closely with interventional radiologist Philip Dombrowski, MD, on EVAR procedures. Image guidance by a skilled and experienced endovascular specialist is essential during endovascular aneurysm repair.
“The first endovascular AAA repair at Cape
Cod Hospital was performed in 1999, working collaboratively with the esteemed vascular surgeon Dr. Bob Scarpato and myself,” said Dr. Dombrowski, who works closely with the vascular surgeons. “This was
the beginning of a truly integrated and cooperative approach across medical disciplines of vascular surgery
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––––[ Vascular Surgery ]––––
and interventional radiology.
We have come a long way in the past two decades with an ever- expanding team, now including vascular surgeons, interventional radiologists, interventional cardiologists and cardiovascular surgeons.”
MULTIPLE ADVANTAGES
There are many variations in repairing an abdominal aortic aneurysm endovascularly, based on its precise location, how rapidly it is growing, its complexity and the patient’s age and overall health, explained Dr. Korepta.
A typical case may involve an aneurysm located below the arteries to the kidneys. In this surgery,
the endovascular specialist will needle puncture or make a tiny incision through the patient’s groin arteries. Guided by fluoroscopy X-ray images, a narrow catheter
is inserted and advanced carefully to the site of the aneurysm. An expandable stent graft is then inserted delicately through the catheter. When positioned just right, the graft is allowed to expand within the artery, while the wire frame pushes against the healthy part of the affected aorta to seal the stent in place.
Once the catheter is in place, blood that previously flowed into the aneurysm will now pass through
the stent graft, instead, and away from the weakened aneurysmal wall of the aorta.
More complex repairs of an aneurysm may be needed when
the aneurysm affects multiple arteries that branch off the aorta, explained Dr. Korepta. That may require a different graft, known as
a “fenestrated” graft because of its tiny cutouts that maintain blood flow to important arteries, like the renal and gut arteries, that may originate from the aneurysm. These grafts are customizable for each patient and built to their specific anatomy (and are FDA approved), she said.
ADVANTAGES AND DRAWBACKS
Whether a patient opts for open or endovascular surgery is usually a collaborative decision with the physician.
Recruited for her state-of-the-art endovascular training, Dr. Korepta noted that the endovascular techniques began in the 1990s and flourished over the last decade alongside similar minimally invasive strategies for cardiology patients, such as the transcatheter aortic valve replacement (TAVR) procedure. EVAR surpassed open aortic surgery as the most common technique for AAA treatment in 2003, she said.


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“Today, we have many older patients because we are living longer; but the older you are,
the less tolerant you become to open surgery,” she noted. “You
can recover a lot faster with endovascular surgery because there is less stress on the heart and lungs. In fact, most people go home from the hospital in about 24 hours after the surgery.”
Current medical guidelines recommend that men between the ages 65 and 75 who have smoked at any time, and men or women with a family history of AAA, undergo
a one-time ultrasound screening for AAAs. Two-thirds of AAAs
are discovered incidentally when doctors perform imaging tests (such as MRI or CT scan) for other conditions.
Even with screening, those at risk should alter their lifestyles, especially if they are smokers.
“Currently, cigarette smoking is the only known modifiable risk factor for AAA development and growth,” said Dr. Korepta. | TJ
Lindsey M. Korepta, MD, RPVI, vascular surgeon, Cape Cod Healthcare
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Jason Saucedo, MD, FACC; Jennifer H. Ladner, MD, FACC; Karl Stajduhar, MD, FACC, cardiology hospitalists, Cape Cod Healthcare


A CARDIOLOGIST BY THE BEDSIDE
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Cape Cod Hospital’s Cardiology Hospitalist program offers inpatient care for cardiac concerns.
By Roberta Cannon
Patients who are admitted to the hospital are now almost universally seen and followed through their inpatient stay by a “hospitalist” physician who specializes in primary care medicine. But not every hospital – particularly if it’s a community-based hospital – has inpatient specialists for patients with cardiac medical issues.
Cape Cod Healthcare recognized the value of this service and in 2014 launched a Cardiology Hospitalist program at Cape Cod Hospital, recruiting two cardiologists trained in treating hospitalized patients with heart-related diagnoses. The program has grown, and there are now four cardiology hospitalists on staff.
The team consists of cardiologists Jennifer Ladner, MD, FACC; Karl Stajduhar, MD, FACC; Tendoh Timoh, MD, FACC; and Jason Saucedo, MD, FACC. Each is skilled in this emerging specialty.
While most cardiology hospitalist programs are set in academic environments, Cape Cod Hospital is leading the trend as one of the first community hospitals in the U.S. to offer cardiology hospitalist coverage. The service started under the direction of interventional cardiologist Richard Zelman, MD, FACC, who continues as medical director of the program.
Cape Cod Hospital and Falmouth Hospital have had
a general Hospitalist program for the past 20 years. Hospitalists are on-site in the hospital day and night
to give patients prompt and complete attention. Increasingly, due to time constraints and more demands on their time in the office, primary care physicians and other specialists are turning over inpatient care of their patients to hospital-based physicians.
Some people are unfamiliar with the hospitalist concept and are surprised that a cardiac specialist is available around the clock.
“For many patients, it may be the first time they’ve seen a cardiologist or they could be visiting and don’t have an established cardiac specialist here,” said Dr. Stajduhar. “The fact that we get to act fully as their doctor while they are here is a really valuable service we provide.”
In the past, cardiologists in group or private practices would assess, admit and follow their own patients during their hospital stay. Depending on what types of interventions, therapies, procedures or surgeries were needed, the patient’s cardiologist took the lead in coordinating with specialists. This was in addition to seeing patients during the day in their offices. As inpatient care has become more complex, this model has become increasingly antiquated.
Because she was in private practice for so many years, Dr. Ladner said she knows how challenging it is for cardiologists to balance rounds at the hospital and then be at their office by 8 a.m. each day to see patients. She joined the Cape Cod Hospital Cardiology Hospitalist program in 2015.
The cardiology hospitalists don’t take the place of
the private or group practice cardiologist, but are an extension of that specialty. Patients who are admitted to the hospital with a cardiac diagnosis meet with one of the four cardiac hospitalists who will evaluate them and discuss their diagnosis, therapies and treatment options. They guide the patient and their family toward the best approach.
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“We have the luxury of being in the hospital all day, which gives us the opportunity to spend more time with our patients and their families. And I can go back and revisit them during the day to follow-up with their response to treatment,”
Dr. Ladner said.
MULTIDISCIPLINARY APPROACH
Cardiac patients at Cape Cod Hospital have the benefit of an academic-type environment in a community hospital setting.
“We’ve created a team of cardiologists who work together and see each other all the time,” said Dr. Timoh.
In the process of diagnosing and evaluating their patients for testing and treatment, they can also tap into each other’s knowledge when they need more information,
he added.
“We talk about our patients
with one another; interact
with the interventionalists, electrophysiologists, and the cardiovascular surgeons; discuss the best approaches; and coordinate everything,” said Dr. Ladner. “I think that is pretty unique to a community hospital.”
While everyone on the Cardiology Hospitalist team is a general cardiologist, each has his or her own specialty within the cardiology service. These include:
• Dr. Stajduhar: electrophysiology (diagnosis and treatment of heart arrhythmias)
• Dr. Timoh: interventional imaging, nuclear medicine, advanced cardiac
imaging (cardiac MRIs, cardiac CT scans) and TEEs (transesophageal echocardiograms)
• Dr. Saucedo: TEEs and nuclear medicine
• Dr. Ladner: TEEs and nuclear medicine
“If I need an additional evaluation for an arrhythmia, I can set
the patient up to be seen for an electrophysiologic problem,” said Dr. Timoh. “If I need assistance with outpatient management for mitral stenosis, I can ask a cardiac hospitalist, like Dr. Ladner, who has more experience and expertise in that area.”
He also likes the seamless access to the interventionalists and surgeons.
“If I need one of those specialists to see a patient, I can just walk next door to speak with them.”
That collaboration goes both ways. When any other specialist needs
a consult for a patient on their service, the cardiology hospitalist can see that patient anytime, day or night, to do an assessment and recommend treatment.
“Most surgical specialists have extensive knowledge in their specific fields, so for anything outside of their purview, they
will call us because we are more experienced in the area of general cardiology,” said Dr. Timoh.
He added that “The specialists don’t have to be concerned with who performs the consultation, because they know we will give them the same guidelines and evidenced- based treatment recommendations, regardless of which one of the four of us sees the patient.”
The cardiology hospitalists are called daily to the emergency department and often to the medical units to consult on patients who need to be assessed for cardiac problems.
As an example, “We may be consulted by the medical service because a patient has experienced syncope (fainting),” said Dr. Stajduhar. “In the course of our
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The Cardiology Hospitalist Service at Cape Cod Hospital is directed by Richard Zelman, MD, FACC and features trained and certified cardiologists who specialize in caring for the hospitalized cardiology patient.


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evaluation, we find the patient
has a cardiac murmur; we do
the tests that show severe aortic valve stenosis, we order any additional tests and get the valve team involved. There may then
be a discussion about a valve replacement, possibly moving toward a TAVR (transcatheter aortic valve replacement) procedure (see page 8) and the patient would be transitioned from our service
to the interventional service at the time the valve is replaced.”
OTHER ADVANTAGES
The Cardiology Hospitalist service provides more than clinical expertise and treatment. The cardiologists offer reassurance, guidance, compassion, rapport and time.
Patients are often surprised about and happy with how much Cape Cod Hospital has to offer in cardiac services, said Dr. Saucedo.
“Somehow, they think we are not going to have the expertise or resources we have available, and then they find out they can have the procedure they need here at the hospital.”
The physicians develop a rapport with the patients, said Dr. Ladner.
“There is this trust they have in us and it’s so nice to be able to follow- up with them after treatment,” she said. “I get positive feedback on the care that we provide, because we go back to see the patients more than once a day to see how they respond to treatment. They also know
that we are keeping their private cardiologist abreast of what is going on with them while they are in
the hospital.”
The Cardiology Hospitalist team at Cape Cod Hospital is providing the best medical care close to home. “The important thing is that our outcomes are as good as or better than most academic institutions
a patient might go to,” said Dr. Timoh. “For many patients
who keep abreast of reports and statistics, they feel quite a bit more comfortable. With the knowledge of our good cardiac outcomes, patients are very pleased to have their care here.” | TJ
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RECOVERING AND THRIVING AFTER CARDIAC REHAB
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The Falmouth Hospital Cardiac Rehabilitation program has been giving cardiac patients a place to rebuild their strength since 1987.
By Roberta Cannon
Robert Aitchison, 80, of Falmouth is such a firm believer in the Cardiac Rehabilitation program at Falmouth Hospital, his slogan is: “It’s the cheapest insurance policy I know to stay alive.”
He should know, having attended the program three days a week for the past 27 years. He begins his day with a 11⁄2 mile walk before he goes to exercise, and on his off days from the program, he does free weights at home. He also continues to play golf and go fishing.
Two other men in the group have been attending the maintenance program for 23 years and 25 years.
“The 90-year-old still skis and travels, and neither of them miss a day of the program,” Aitchison said.
Statistics show that each year, close to 1 million Americans have a cardiac event. And of that number, more than 30 percent will have a second one that could be fatal, according to the American Heart Association.
The benefits of cardiac rehabilitation following a cardiac event have been shown to reduce mortality rates by 25 percent overall and reduce symptoms of angina, dyspnea and fatigue.
While one of the first mentions of the benefits of exercise after a heart attack was noted in 1772 by English physician William Heberden, it was not accepted medically until relatively recently.
“Before the 1990s, cardiac rehab was thought to be a great idea, but the benefits were never proven,” said John Guerin, MD, FACC, Falmouth Hospital’s medical director of the Cardiac Rehabilitation program. “Finally, there were some prospective, randomized
and very well-run studies that really proved the benefit of cardiac rehab to all comers. The studies solidified what most people thought about the positive effects of exercise and rehabilitation on cardiovascular health.”
In that respect, Thomas Sbarra, MD, now a retired Falmouth Hospital cardiologist, may have been
a bit ahead of the curve. He opened the Cardiac Rehabilitation program at the hospital in 1987 with Gretchen Sweeney, RN, a cardiac nurse. They had four patients who either had stable angina or a heart attack, according to Susan Crider, RN, BSN, clinical coordinator of the Falmouth Hospital Cardiac Rehabilitation program.
Cape Cod Healthcare also offers a Cardiac Rehabilitation program in Hyannis at Cape Cod Healthcare Cardiovascular Center, under the direction of cardiologist Elissa Thompson, MD.
CHANGE IN SCOPE
The scope of the Falmouth Hospital Cardiac Rehabilitation program has evolved since opening its doors 30 years ago.
“Originally, the focus was on education after a heart attack,” said Dr. Guerin. “Now, it is really about helping you get back on your feet and setting you up for better lifestyle choices and activities.”
Phase I of cardiac rehabilitation begins during the hospital stay and is designed to help the patient achieve a level of performing simple household tasks, according to the National Institutes of Health. There is often not time during the patient’s hospital stay for the more in-depth education about illness, treatment, risk factors


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John J. Guerin, MD, FACC, cardiologist, medical director of cardiac rehabilitation, Falmouth Hospital


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and lifestyle changes, so these discussions are part of the second phase of rehabilitation.
Phase II is the outpatient monitoring cardiac rehabilitation program, where patients can exercise and learn the positive effect it can have on their return to cardiovascular health. Changes in lifestyle, such as smoking cessation, diet modifications and weight loss, can be difficult, but participants have the support of staff and others in the program to get them through these challenges.
Phase III is a maintenance program for life that emphasizes the continuation of risk modification and an exercise program.
COMPONENTS OF THE PROGRAM
The Cardiac Rehabilitation program at Falmouth Hospital is nationally certified by the American Association of Cardiovascular
and Pulmonary Rehabilitation, said Crider.
“Because of the certification, education is a big component of cardiac rehab,” she said.
The 36-session outpatient program includes cardiovascular strength and flexibility training, daily education classes, referrals to
the hospital’s diabetes education program, if necessary, referrals for counseling by a social worker, home exercise transition, and a maintenance program.
The program is covered by most health insurance products, including Medicare, and eligibility for the program is based on one of the following diagnoses:
• Myocardial infarction
• Coronary bypass surgery • Stent placement
• Valve replacement/repair • Heart transplant/repair
• Stable angina
• Congestive heart failure • Cardiomyopathy


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Patients are referred to the program by their primary care physician or cardiologist. Once their referral
has been reviewed by Crider for
the appropriate diagnosis, potential participants meet with Dr. Guerin.
“I see the patients initially to review their medical history and diagnosis, and to make sure they are clinically stable,” said Dr. Guerin. “I continue to follow them through the program and receive updates on their progress in meetings with the nurses and exercise physiologists.
If any clinical questions or concerns arise, we discuss them and I funnel the information back to
their cardiologist.”
Participants exercise three days a week and spend about two hours at each session. One hour is dedicated to cardiovascular exercise, strength or flexibility training.
Cardiovascular exercise includes work on:
• Treadmills
• Stationary bikes or recumbent bikes
• Nu-Steps (a stationary workout machine that simulates walking, running or hiking)
• Rowers
• Sci-Fits (combination arm ergometer/recumbent bikes)
• Airdynes (bikes with resistance)
The strength training portion involves the use of free weights, while flexibility training utilizes upper and lower body stretches. Heart rates are monitored during exercise by telemetry, oximeters, manual assessment and blood pressure readings taken before and after the workout.
During the other hour of the cardiac rehabilitation program, before or after exercise, patients participate in a class covering
a variety of topics related to improving their lifestyle.
Some of the many topics covered in the classes include:
• Diaphragm breathing – a basic relaxation technique
• Reading food labels
• DASH diet (Dietary Approaches to Stop Hypertension)
• Pharmacy – learning about your medications
• Guided imagery – a therapeutic technique to help the participant enter a relaxed state using mental visualization
• Affirmations – positive statements to say to yourself to counteract negative thoughts
and beliefs
• Chair yoga – promotes increased circulation, normalizes blood pressure, creates a positive outlook
• Symptoms of a stroke, myocardial infarction
• Intimacy and heart disease
One of the many pluses of the program is the positive changes that patients don’t expect.
“The program goes beyond the goals you set for them on paper,” said Paula Smith, DPT, Falmouth Hospital’s director of rehabilitation, Sleep Lab and EEG services,who oversees all of the programs and staff in the rehabilitation department.
One of the favorite descriptions of the monitoring program is that it is “patient-owned,” she said.
“One patient told me he had no idea how much the social network plays into the success of this program. Our patients are our best recruiters for each of our programs. The patient network keeps everyone engaged, invested and motivated to navigate through these truly life- altering programs. The patients are a thrill to interact with.”
FOLLOW-UP PROGRAMS
Once patients have “graduated” from the monitoring program, they have the option of continuing in the maintenance or wellness programs.
Group members can come to
the maintenance program two
to three times a week at specific times between 6:45 a.m. and
6:30 p.m. and have their blood pressure, weight and blood sugars (for diabetics) checked, and have supervised exercise.
The wellness program is for patients who have not had a cardiac event but may be dealing with
high cholesterol, weight gain or high blood pressure, or just want
a supervised exercise program without going to a sports club or gym. They focus on goal setting, some education and
strength training.
The Cardiac Rehabilitation program also has an employee wellness program that allows staff to exercise during the maintenance and wellness classes. They can also have their blood pressure and blood sugars checked and have access to informational material the staff prints out.
“Our patients are our customers, not just a diagnosis on a page,” Crider said. | TJ
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Elissa Thompson, MD, cardiologist; medical director of cardiac rehabilitation, Cape Cod Hospital; medical director of Cape Cod Healthcare Heart Failure Clinic


PREVENTING RE-HOSPITALIZATION AND PREMATURE DEATH FROM HEART FAILURE
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The Cape Cod Healthcare Heart Failure Clinic is helping patients learn how to manage symptoms and avoid readmission.
By Laurie Higgins
In the spring of 2017, Tom Hickey was having so much trouble breathing, he couldn’t sleep at night. He thought he had a bad chest cold, but when he saw his primary care physician, he learned he had a more ominous diagnosis.
“He checked me out, and he looked at me and said, ‘We have a serious situation here. Ordinarily, I would be calling 911 and getting you in an ambulance to the hospital because you’re having congestive heart failure. But there is a new clinic for congestive heart failure, so let me make a call over there.’”
An hour later, Hickey, 73, was at the Cape Cod Healthcare Heart Failure Clinic on Main Street in Hyannis, being examined by nurse practitioner Shannon List, NP, who started him on diuretics right away and elevated his feet to take the strain off his heart. He was stabilized in a few hours and sent home with medication and detailed instructions on how to lose weight and avoid sodium. His follow-up care at the clinic included weekly visits at first, and then bi-weekly visits, which helped him stabilize his condition.
“It’s very easy to talk with Shannon,” Hickey said. “She’s very personable and very caring. My wife frequently goes with me so that she can understand how to approach my low-sodium diet.”
With careful monitoring from the Heart Failure Clinic as well as from his cardiologist Lawrence McAuliffe, MD, FACC, Hickey is a success story. He
avoided hospitalization, which would have been the only option prior to the opening of the clinic. Repeat echocardiograms have shown significant improvement in his heart’s “ejection fraction,” the measurement of the percentage of blood leaving the heart each time it contracts. His rate went from 20 to 25 percent when he entered the clinic to 50 percent (within normal range) six months later.
WHAT IS CONGESTIVE HEART FAILURE?
Hickey’s diagnosis is not a rare one. Congestive heart failure has become an epidemic in the U.S., with more than 6.5 million Americans suffering from it. That number is expected to increase by 46 percent by 2030, according to the American Heart Association (AHA). The economic costs are projected to increase from $20.9 billion in 2012 to $53.1 billion in 2030, according to a 2014 AHA policy statement, “Forecasting the Impact of Heart Failure in the United States.”
What cannot be measured is the cost in human suffering and the toll it takes on a person’s quality of life, particularly when their condition requires frequent hospitalizations.
“When patients are diagnosed with congestive
heart failure, their five-year mortality rate is 50 percent, and that goes up exponentially if they are re-hospitalized with congestive heart failure,” said cardiologist Elissa Thompson, MD, medical director of the Heart Failure Clinic.
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The most dangerous time for these patients is the first 30 days after hospitalization. With that in mind, Cape Cod Healthcare developed its innovative clinic to help educate patients on ways to manage their condition and stay out of the hospital. Instead of waiting a week or two to see their doctor, patients who leave the hospital after being diagnosed with congestive heart failure are now at the Heart
Failure Clinic within 24 to 48 hours after discharge.
Congestive heart failure is a lifestyle illness. Age plays a role, but hypertension, obesity and diabetes are all strong contributors. The condition occurs when the heart cannot meet the metabolic needs
of the other organs in the body.
There are many different reasons for this, but two common ones are a previous heart attack and high blood pressure, coupled with poor lifestyle choices.
The type of heart failure that can occur in someone who has had
a heart attack is called “reduced ejection fraction” or “systolic congestive heart failure.” It means that the heart is not strong enough to pump the blood as it should, according to Dr. Thompson. When blood pressure is out of control, the heart becomes stiff instead of soft and supple. Even
if it contracts adequately, it can have a hard time relaxing and filling with blood. The relaxation phase of a heartbeat is crucial.


If either of these things happens, fluid backs up into the lungs. The condition can also cause renal failure, significant swelling in the lower extremities, and infections like cellulitis or ulcers on the legs.
Diuretics are the first line of defense with heart failure because they
help eliminate the excess volume of fluid to ease the load on the heart. Sodium restriction is also critical to ensuring that fluids aren’t retained. Dr. Thompson also recommends
45 to 50 minutes of exercise or the equivalent of 10,000 steps a day. She tries to promote exercise by encouraging patients to enroll in Cape Cod Healthcare’s 12-week Cardiac Rehabilitation program.
EDUCATION AND TLC
The goal of the Heart Failure Clinic is to prevent patients from resorting to the same behaviors that exacerbated their condition by giving them new information and strategies.
“We support them with a lot of education and a lot of TLC,”
Dr. Thompson said. “Shannon spends an hour and a half with each patient on their intake examination, going over lifestyle issues and how people can help themselves at
home so that they recuperate rather than decompensate.”
The patient also continues to be seen by their cardiologist.
The clinic has a specialized set of examination rooms with IV infusion chairs and monitoring devices similar to those in the emergency department.
“We can see patients not only when they come out of the hospital,
but also those (like Tom Hickey) who are referred by primary care physicians who are worried about
a patient having congestive heart failure,” Dr. Thompson said. “They can come here, and we assess them and get them medications and treat them aggressively, and help them avoid that hospitalization.”
PATIENTS THRIVE
Lifestyle vigilance is essential to controlling congestive heart failure, Dr. Thompson said. Each congestive heart failure patient at the hospital
or the clinic is given a folder with easy-to-understand information. Instructions are color coded with traffic light symbols, letting the patient know the correct sodium intake, diet restrictions and weight. The goal is for patients to monitor themselves and weigh themselves every single day. If their symptoms are in the green area of the sheets, they know they don’t have to be worried. If they are in the yellow area, they are encouraged to call the clinic
and make an appointment to adjust treatment. If they fall in the red area, they need to get an immediate evaluation and should call 911.
Some patients with heart failure
are quite ill and need a higher level of care. They are triaged at the clinic and referred to palliative care services at the Cape Cod Healthcare Visiting Nurse Association of Cape Cod Hospice.
“These patients really end
up thriving with that kind of individualized care in the home where they can have access to appropriate foods, take medications on time, and have eyes on them, weighing them and assessing
their symptoms every day,” Dr. Thompson said. “If they do start
to decompensate, we can act immediately to prevent them from getting worse.”
As scary as congestive heart failure is, being hospitalized for it is not an automatic death sentence. If patients manage their symptoms, restrict salt, change their diet
and exercise, their likelihood
of long-term survival improves dramatically, Dr. Thompson said.
“We’re really trying to break the cycle of re-hospitalization, to keep people healthier for longer and prevent premature death from this disease.” | TJ
Heart disease accounts for one in seven deaths in the U.S., and
8.5 percent of those deaths are attributed to congestive heart failure.
A complex clinical syndrome, there is no diagnostic test for heart failure, no simple pass/fail determiner. As a result, it is largely a clinical diagnosis based upon a careful history, physical examination and tests.
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IMAGES THAT HELP GUIDE ADVANCED-CARE CARDIOLOGY
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With the latest heart procedures comes the need for a specially trained cardiologist to interpret detailed images.
By Claudia Dolphin
When cardiologist Tendoh Timoh, MD, FACC, arrived at Cape Cod Healthcare in the fall of 2016, he brought with him a level of expertise usually reserved for academic medical centers. Board certified in internal medicine, cardiovascular disease, echocardiography, cardiac CT and nuclear medicine, Dr. Timoh did his fellowship in advanced cardiac imaging at the National Institutes of Health (NIH) in Bethesda, MD.
“We needed to have more sophisticated imaging in order to be able to perform these advanced procedures,” said Donald Guadagnoli, MD, senior vice president
and chief medical officer of Cape Cod Healthcare. “If you are going to be offering advanced cardiac imaging, you also need a fellowship-trained cardiologist to help interpret that imaging. So this is really a product of the ever-advancing technology that we’ve been offering to the community.”
Under Dr. Timoh’s guidance, three new diagnostic cardiology services are being offered at Cape Cod Hospital in Hyannis:
• Cardiac Magnetic Resonance Imaging (MRI)
• Cardiac Computed Tomography (CT)
• 3-D Trans Esophageal Echocardiography (TEE)
All provide the most advanced ways of looking at the heart and the cardiovascular system.
MRI TECHNOLOGY
Cardiac magnetic resonance imaging (MRI) is a painless, noninvasive test that is used to evaluate the structure of the heart and to assess the health and viability of its functioning. With the 1.5 Tesla machine located at Cape Cod Hospital, detailed pictures of
the heart are obtained using powerful magnets and radio waves. In some cases, the test requires the administration of intravenous contrast solution.
Diagnostic cardiac MRI is used to evaluate the size and shape of the heart, and can identify damage that has occurred due to a disease, virus or heart attack. There are three main uses for diagnostic cardiac MRI, according to Dr. Timoh.
• A visual of the heart: “Cardiac MRI can tell us what the heart physically looks like, which is especially important if there has been a heart attack or an infarct in the past. If so, we look to see if there is any thinning or scarring of the muscle,” said Dr. Timoh. “It can tell us of cancers or other disease processes affecting the muscles of the heart.”
• The location of damage: Scarring in the heart muscle is a known cause of cardiac arrhythmia. Knowing exactly where the damage occurred allows an electrophysiologist - a specialist who diagnoses and treats heart rhythm disorders - to precisely ablate the area to restore normal rhythm.
• Assessment of pumping action: Cardiac MRI can evaluate the pumping function of the heart as well
as measure blood flow. It highlights impairment and determines the extent of any leakage or regurgitation.
“We are able to calculate just how leaky those valves are, or how much stenosis (narrowing) is present,” said Dr. Timoh. This information is essential for interventional cardiologists, who perform procedures like angioplasty and other minimally invasive procedures like transcatheter aortic valve replacement (TAVR) or percutaneous mitral valve repairs (MitraClip®).